| Joint UNFPA Mongolia and China Proposal on
STIs/HIV Prevention among Youth, Mobile and Most at Risk Populations
Mongolia is a landlocked country between Russia and People’s Republic of China with a population of 2.7 million. Since recently, Mongolia is a low-middle income country with GDP of $1,862 USD per capita1. With increasing revenues from mining, it is expected that economic growth will accelerate from 8.9% in 2008 to about 10% per annum by 2015.
Scarcely populated, Mongolia is urbanizing at a fairly rapid pace and currently close to 60% of its population lives in the urban areas with 40% living in Ulaanbaatar. There are other big cities include Darkhan and Erdenet, each with a population of around 100,000. The population of Mongolia is young, 49.1% is younger than 25 years of age, and the median age of the population is 26.2 years of age. The proportion of young population aged 15-34 is 39.3%2. There is widespread youth unemployment, with school and university graduates at present taking from 1.6 to three years to secure work Current estimates of the number of people living below the poverty line range from 27 percent to 35 percent nationally3.
The biggest mining industries are now concentrated in Umnugobi province including the coal mines in Tavan Tolgoi area and copper and gold mines at Oyu Tolgoi. The coal and copper ore are transported to China by trucks through the land ports. These areas have become hubs for internal migration and the local population is increasing quite rapidly.
Mongolia and China border is the two thirds of the total Mongolia border, and runs across Inner Mongolia Autonomic and Xinjiang Autonomous Regions. As the biggest economic partner of Mongolia, there many land ports in all provinces of Mongolia and estimated 1 million people crossing it from both sides in a year.
Situation of HIV and Sexually Transmitted Infections (STIs) in Mongolia and China
Mongolia has, so far, remained a low HIV prevalence country, with a cumulative total of 89 cases as of April 2011 and an estimated adult prevalence of less than 0.02%, despite of the fast growing concentrated epidemics of its neighboring countries Russia and China. However, Mongolia has experienced a sharp increase from 5 to 89 in number of cases over the last seven years. Mongolia is a special case in that it appears to be in a latent stage epidemic with low HIV prevalence across the general population and vulnerable groups4.
The main transmission mode is sexual; and men having sex with men (MSM) are currently the group most at risk of HIV infection in Mongolia accounting for 80% of all cumulative cases5. The country runs the risk of a further acceleration of the spread of HIV given Mongolia’s relatively high prevalence of sexually transmitted infections (STIs), based on the 2008 study on STI prevalence among pregnant women attending the ANC clinics, which is the best estimate of STI prevalence in the sexually active adult population. According to this study one in four women had at least one of four STIs (chlamydia, trichomoniasis, gonorrhea or syphilis) they are tested for6.
Figure 1. Cumulative number of Reported HIV Cases, totals, males & females 1992-2011, Mongolia (Source: National Center for Communicable Disease)
Among female sex workers (FSWs), 18.3% had syphilis, 24.5% had chlamydial infection and 15.6% had gonorrhea7.
People under the age of 25 comprise half of the Mongolian population. However, the Second Generation STIs/HIV surveys have identified significant high-risk behaviors to warrant youth an important group to monitor. With 43% of young males and a quarter of young females have reported to having multiple sexual partners, low exposure to prevention programs (11%), and low condom use at last high risk sex non-commercial non-regular partner (males 60.9%, and females 46.2%). This group includes particularly young men who are highly mobile, many with disposable incomes for whom all the right conditions exist for potentially high risk to HIV. In MSM, HIV prevalence is three times higher in the <25 age group than older age group8.
Further, with the growing unemployment rate in young people, girls engage in sex work and related high risk activities to earn money exposing them to greater risk of STIs/HIV. As Mongolia’s linkages to the HIV epidemics in its neighboring countries increases, the youth and other mobile population groups are becoming more vulnerable, especially with the shortage of effective life skills, education, youth friendly health services and among the mobile populations, and increasing disposable incomes. Although the HIV epidemic appears confined among most at risk population (MARP) groups, such as MSM and FSWs, there is an increasing risk of the infection spreading widely into the general population based on the high prevalence of STIs. There are estimated up to 19,000 FSWs and 15,000 MSMs in the country9. About 10% of total HIV cases are FSWs10.
Furthermore, the percentage of young men and women who correctly identified ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission were 22.3 and 18.4% respectively, the percentages among MSM and FSWs were 56.3 and 50.4%. If 70.4-78.6% of MSM and FSWs have been reached by HIV prevention programmes, only 27.0-31.5% of the mobile men and male STI clinic clients were reached by these programmes. These data clearly show the need to focus on young women and men, and mobile population groups to prevent the spread of the infection into a general population11.
First HIV case in China was in 1985. Out of over 3,000 counties of China, 43 reported more than 1,000 cases and five reported more than 5,000 cases. If the epidemic was first reported among injecting drug users (IDU) now it is widespread among other high-risk population, including MSM and FSWs. Signs of generalized epidemic is now notable in Xinjiang, where more than 1% of pregnant women attending to antenatal clinics have been detected with the infection12.
China has an estimated 150 million internal migrants, the majority of which are seasonal, rural-to-urban migrant workers. Most of them are young, either unmarried or living apart from their spouses and children. They are relatively poorly educated and lack professional skills to access to better paid jobs. Social or health insurance for migrants is almost non-existent, although the government has started to offer better social welfare to this population. These factors place the female migrants in a disadvantaged position and increase their susceptibility to engaging in sex work. Sex work in China is illegal; nevertheless it is a thriving business. Its scale and variety is broad, ranging from luxury club- or hotel-based to street-based. It caters for the clients of different financial status.
As the trade routes between China and Russia become increasingly better connected through Mongolia’s soon to be completed regional highway, along with the development of the mining areas that border China, migration and intermingling of the populations will increase across these three countries. Mobile and migrant workers and various security and border officers and middle level managerial workers (temporary workers) and petty traders are at even greater risk of both contracting the STIs and HIV as well as bridging HIV and STIs transmission to the general population in both countries. Their increased disposable income allows them to frequent commercial and sex entertainment establishments and enables them to offer money, food, and clothing to rural women and girls in exchange for sexual favors.
Documented increases in risk behavior associated with mobility and the growing number of mobile and migrant workers in the country provide an ideal environment for the rapid spread of HIV infection13. Although the prevalence of HIV/AIDS is low, Mongolia is at a very high risk of an accelerated HIV spread due to its relatively young population, because of its relatively open societal norms towards sexuality, the high STI prevalence indicating the presence of high risk behaviors and critically, for the purpose of trade, tourism, study or labor, the increased mobility of the petty traders, high school and university students youth looking for vacation jobs, the business men and women and the temporary workers posted to these border towns for short periods because of high turnover of government and private sector company staff at these border towns and exposure to the growing epidemics in the neighboring countries, China and Russia. A highly focused set of prevention strategies based on evidence will be required and to be urgently implemented in close collaboration with the stakeholders in the neighboring countries to maximize their impact.
From China’s perspective, the areas surrounding the border points do not always report the high STIs/HIV prevalence. Yet, those who cross these points are traveling to/from bigger cities for trade, tourism, study or labor. Therefore, targeted prevention activities in these areas provide excellent opportunities to equip the people with the knowledge and encourage their behavioral change.
Condom use is the most effective prevention tool for sexual transmission of HIV and STIs. 100% Condom Use Programme (CUP) has been implemented widely in both countries to encourage female sex workers to require the use of the condom. Yet, in the context of sex work, clients have the final decision-making power on condom use. Thus, it is vital to include the potential clients of sex workers in the HIV education and condom promotion programmes.
The cross-border HIV prevention project (2009-2011)
During the present phase of the Cross-border HIV Prevention Project” (2009-2011), UNFPA Mongolia and China offices with the financial assistance of the Government of Luxembourg, the implementing partners, including UNFPA, and Red Cross Societies of China and Mongolia, have targeted female sex workers and mobile groups consisting of petty traders, high school and university students youth looking for vacation jobs, the business men and women and the temporary workers posted to these border towns in two areas of China-Mongolia border: Erlian City of the Inner Mongolia Autonomous Region bordering with Zamiin-Uud district of Dornogobi Province of Mongolia, and Qinghe County of the Xinjiang Uyghur Autonomous Region of China bordering with Bulgan district of Khovd province of Mongolia.
The project has addressed key issues related to the exposure of the above mentioned mobile populations in border areas to high risk behavior such as using the services of sex workers and engaging in opportunistic non-commercial sex. The local Red Cross Societies have increased their capacity in addressing STIs/HIV prevention and mutual collaboration. However, key issues like availability and utilization of diagnostic and treatment services, and awareness among resident populations have yet to be addressed.
Therefore, the proposal intends to continue strengthening the STIs/HIV prevention in the border areas both in Mongolia and China, and also expand it to bigger cities of Mongolia from where most of these above mentioned mobile population groups come from the newly emerging mining towns which will experience a significantly increasing influx of migrant works and “camp followers”. The project also focuses on sustainable health services for youth in general, and most at risk young populations (MARYPs) including FSWs and their potential clients.
Geographic areas with highest risk for STIS/HIV transmission
The two border areas of Mongolia have been covered through the current phase. In addition, the border of the Dornod province is also a significant crossing area for traders.
Bulgan (Khovd, Mongolia) - Qinghe County ( Xinjiang Uygur Autonomous Region, China) border14
Khovd province is located in Western Mongolia, has 17 soums (rural districts) and a total population of 88,50515. Three soums have border points, with Bulgan soum being the largest border point soum, with a population of 9,266 as of December 201016. Bulgan soum is located 500 km west from the center of Khovd aimag. Some of the local residents belong to the Kazakh minority. Estimated 23,186 people from five neighboring aimags cross the border through five temporary17 border points in Bulgan soum. The majority of these people are travelling for trade and visiting family members. The Yarant border point functioned during the second half of each month, but since January 2011 it started working at full capacity throughout the year. In the first quarter of 2011, some 4,300 people have crossed this border. The majority of these people are travelling for trade and visiting family members. In recent years, the number of hotels, bars, trading stores, dining places in Bulgan soum has steadily increased.
Qinghe County is located in the Xinjiang Uyghur Autonomous Region of China and is under the administration of the Altay Prefecture, bordered with Bulgan soum, Khovd province of Mongolia. It covers a total area of 15,722 km² with a population of 60,000.
The border port is located in Takeshiken Township, which is in the southeast part of Qinghe County and is 106 km from Qinghe County Capital. The township covers 1,513 km² with a population of around 4000 (96% of Kazakhs and 4% of other nationalities including Han, Hui, Mongolians, etc.). Takeshiken Port is the second largest port to Mongolia in China and the largest one in Xinjiang. The border is currently open throughout the year as a bilateral border and an estimated 10,000 people cross the border annually. With expansion of coal and gold mining industry in the border area, an increase of migrant miners is expected between April and October, when weather is suitable for outdoor work.
Qinghe County is a low HIV prevalence area in Xinjiang province. 2 new HIV infections were found by the Exit and Entry Health Examination Station of Takeshiken Port and both are drug users. The STI prevalence is low in Qinghe County – estimated 20 to 30 STI new cases a year.
Zamiin-Uud (Dornogobi, Mongolia) – Erlian City (Inner Mongolia Autonomous Region, China) border18
Dornogobi province has 14 soums, total population is about 58,31819. Zamiin-Uud is one of the soums and a vital crossing point on the Chinese Mongolian border, which neighbours with Erlian city of China that is 8 km from Zamiin-Uud. A total of 13,799 people were registered as permanent residents in Zamiin-Uud in November 2010, whereas non registered residents are estimated at 3,500-4,000 people20. On a daily basis approximately 3,000–5,000 people cross the border point. Erlian city of China is a fast growing market city, where many traders from Mongolia come to purchase goods and Chinese bring goods from all over the country to sell. The town offers a number of entertainment outlets and red light establishments to visitors offering erotic shows and commercial sex work involving young women and men from both sides of the border.
Erlian City is located in the north of Inner Mongolia Autonomous Region, bordered on Zamiin-Uud District of Dornogobi Province, Mongolia. Erlian City is China’s largest border port opening to Mongolia and one of the countries’ 13 border cities opening to the outside world.
The total area of Erlian City is 4,015 square kilometers with a total population of around 100,000. 80% of the total population is migrants (around 80,000) and majority is the young and middle-aged. In year 2010, the entry and exit population in Erlian port reached 1.78 million (887,900 for exit and 896,200 for entry).
The first HIV positive case in Erlian City was reported in year 2004. So far, 10 reported cases were found among the entry and exit population by the Entry and Exit Administration Bureau of Erlian City and 4 cases were reported among the migrant population living in Erlian City by the Health and Disease Control sector of Erlian City.
Choibalsan (Dornod, Mongolia)
Dornod is the easternmost of the 21 aimags (provinces) of Mongolia. The aimag has 14 soums, a total population is about population is about 73,62521. Three quarters of the total population are young people below the age of 35, and there are several colleges and university branches. Its capital is Choibalsan, the fourth-largest city in Mongolia. The province neighbours with Russia in the north and China in South and East.
The traders from the Eastern provinces of Mongolia cross the border located at 90 kms from Choibalsan soum. The newly emerging uranium mining and oil industry have substantially increased the traffic and the influx of migrant workers. Eventually, sex work has become a significant problem.
Bigger cities in Mongolia
There are 3 big cities in Mongolia, Ulaanbaatar, Darkhan and Erdenet. Ulaanbaatar now has a population over one million, the others about 100,000. These cities are the country`s education center and there are about 100 state and private tertiary academic institutions. Darkhan and Erdenet are the second and third largest cities in Mongolia and have several colleges. According to the Statistical Department of Ministry of Education, Culture and Science (MECS) informed that there are totally 121,730 students are studying at the universities and colleges of Ulaanbaatar city, and slightly more than a half (66,687) came from the countryside. Among the students who come from countryside, the majority live in student dormitories22.
Unemployment is high among university and college graduates, about 60% not being able to find jobs after graduation23. As a result they tend to travel to the border towns and the mining areas especially during summer for purposes of tourism work, trade. This is further reinforced by the fact that there is a lack of recreational facilities and youth-friendly SRH services in bigger cities of Mongolia. All there may put students at high risk for acquiring STIs, including HIV infection.
In Mongolia, the risk of spreading the STIS/HIV is increasingly becoming associated with the development of the mining sector. Since 2009, coal and copper mining in Umnugobi province started attracting a new influx of workforce to the area and development of the support services mainly in two soums Tsogtsetsii and Khanbogd.
Thousands of migrant workers now are working at the mines, and on road construction, away from their homes. Population in the above two soums that has averaged 2,500-3,000 people have quickly quadrupled in the past two years reaching 10,000-13,000, and it is still growing. The soum hospitals staffed and budgeted as before the rush, is unable coping with the increased demand.
The following tools have been used to conduct the problem analysis: review of available secondary sources, social mapping exercise, partner mapping exercise and stakeholders meetings, one on one or as a group. The main population groups at risk of spreading HIV from MARP to general population have been identified as follows: migrant and mobile population including temporary workers, truck drivers, petty traders (female and male), men with disposable income, men with authority and young people aged between 15 and 35.
With the new developments in the mining and construction sectors of Mongolia, cross border labor and other types of migrant workers and temporary workers are also becoming an important vulnerable group. A majority of these migrant and temporary workers are men away from home for months at a time and are thus exposed to a certain lifestyle that both poses and increases their risk and exposure to STIs and HIV.
The interaction between the mining workforce, local communities, and sex workers can, potentially, create a high-risk environment for the spread of HIV infections through unprotected sex or even injecting drug use. The total number of cross border travelers (internal and external) is not known, but it is estimated that nearly one million persons cross the border each year.
The social mapping exercise and meeting with stakeholders has shown that men with disposable income and men with authority, such as customs or immigration officers, also constitute a high risk population group as potential clientele of female sex workers. Young women and students, who are working in temporary jobs, often engage in sexual relations with this group of men to supplement their income or, to find safe accommodation. However, very little is known about the behaviors of this important and influential bridge group.
We have also identified young petty trading women as another one of the vulnerable groups through the social mapping exercise that was conducted on April 4, 2011 with main stakeholders. These women are likely to make temporary relationships with mobile or local men. They may also exchange sexual favors for immigration, custom and police support, and also with drivers (taxi, trucks, etc) 24.
The above-mentioned social mapping exercise also found that adolescents and students do not have appropriate safe places to meet and there is a lack of opportunities for safe and creative extracurricular activities. They tend to spend their leisure time meeting friends, sitting in internet cafe, shopping, and doing part time jobs in establishments with high staff turnover. They spend evening hours in clubs, bars, pubs, and they often go for outings, parties, karaoke, sauna or nightclubs.
The lack of safe meeting places and opportunities for safe and educational extracurricular activities is seen by many young people as the main reason that many take up risky behaviors such as smoking, drinking, casual sex and some of them even use drugs. Young people have a limited access to HIV and STI prevention information and in particular to health services. Lack of parental care and supervision, and, traditionally, lack of open communication on sexual and reproductive health matters further increases their susceptibility to indulging in risky behaviors that further increases their vulnerability to STIs and HIV infection.
According to a survey, about 68% of the first and second year students live in dormitories. Majority of them do not have TVs, or personal computers. Some dormitories have common TV areas where they usually watch soap operas. The main sources of information for them are their friends and classmates who live outside of dormitories. Most of the students enrolled in the study said that, when they have free time, they visit other rooms, and talk to friends in the dormitory.
Most of the dormitories did not have a room or space which the students can spend their free time meaningfully. Most of the students did not know where to go if they got sick. They usually take self treatment based on roommates’, friends’ and maybe a pharmacist’s advice.
Students often use ineffective methods such as calendar to avoid pregnancy. Boys often said they would use condoms with casual partners, but would not use condoms with their girlfriends. Students usually purchase condoms from drugstores and if they run out of money, there don’t use condoms at all25.
Additionally, due to globalization and rapid technological development young people have better access to various types of information including pornography, contact details of local sex establishments from friends and other young people in the local area.
Young people are greatly influenced by peer pressure, prevalent attitudes and trends and the expectation to be distinct in terms of being fashionable and stylish. As a consequence they are often in need of money to buy expensive branded products. To satisfy their increasing needs, they are willingly take risks. They are not mature enough to control their drinking and end up engaging in very high risk behaviors often with long-lasting consequences.
Unlike its neighbors, where injecting drug use is widespread and one of the major drivers in the HIV epidemic there, the extent of injecting drug use in Mongolia is unknown, as this population group is not officially monitored.